Aim of examination

Gangrene or not?

What is the cause?

Demarcated or not?

Which type?

Cardinal signs (Gangrene or not?)

Oh! Press and see how color fades

Oh! Odor

Press Pulse: Loss of pulsation and Sluggish capillary circulation

See Sensation Loss of sensation

How Heat Loss of heat

Colour Color Fixed color changes / Blue and later black

Fades Function Loss of function

What is the cause?

Traumatic Direct trauma Crushing

  • Pressure ‘bed sores’
  • Indirect trauma Injury of main vessel
  • Delayed Vascular repair after tissue death


  • Burn
  • Frost-bite
  • Trench foot


Specific Clostridial gas gangrene

Non specific:

  • Carbuncle (Skin)
  • Anaerobic cellulitis (Skin)
  • Cancrum iris (Mouth)
  • Noma vulvae (Vulva)
  • Phegendena (Breast)
  • Melenery’s ulcer (Perineum and abdominal wall)
  • Fournier syndrome (Scrotum)


  • Thrombosis Atherosclerosis
  • Diabetes
  • Beurger’s disease
  • Artritis
  • Embolic
  • Vasospastic Raynaud’s disease
  • Ergotism

Venous Major outflow obstruction


  • Diabetes
  • Syringomyelitis
  • Leprosy

Demarcated or not?


    • Depend on (VascularityInfectionTrauma)
    • Stages (Zone of demarcationLine of demarcationPlane of demarcation)
    • Line of demarcation should be (Complete ‘all around’Well definedConstant place)
    • Plane of separation may be
      • Ulceration at the expense of dead tissue ‘depth’
      • Suppurative at the expense of living tissue ‘abrupt stop’
    • Failure of demarcation (In continuity – Skip lesions – Dye back phenomenon)

Which type?

Moist vs. Dry

  • Swollen  vs. Shrunken
  • Stretched skin   vs. Wrinkled skin
  • With bullae  vs. No bullae
  • Soft  vs. Hard
  • Less dark  vs. Darker in color
  • Less odor  vs. With characteristic odor
  • May be septic or aseptic

Causes of Moist Gangrene 

  • Sudden arterial obstruction
  • Venous obstruction
  • Generalized edema
  • Liquefaction of tissues

Ischemic ulcer


Ischemic ulcer


Number Single or multiple
Site Tips of toes – Over pressure points
Shape Most often elliptical
Size and depth Vary from small, deep lesions, a few millimeters across, to large, flat ulcers 10 cm or more wide on lower leg

Usually very deep and may penetrate down to and through deep fascia tendons bone or even underlying joint

Floor Grey-yellow sloughs covering flat, pale, granulation tissue
Edge Punched out if no attempt at healing

Sloping if begin to heal

Margin Blue-grey color

No lipodermatosclerosis

Discharge Clear fluid – Serum – Pus
Arteries Distal pulse is invariably absent
Nerves There may be loss of superficial and deep sensations, weakness of movement and loss of reflexes if the ulcer is caused by neuropathy
Bones and joints May be exposed


Lymph nodes Not normally enlarged
Extent and motility May stuck to, or be part of, any underlying structure

And it is quite common to see bare bone, ligaments and tendons exposed in the base of an ischemic ulcer

Tenderness Very tender

Removing of dressing can cause exacerbation of pain lasts for several hours

Peripheral arterial system – Clinical Examination


Peripheral arterial system


Color changes

 Screen Shot 2016-06-19 at 2.35.53 PM

Trophic changes and Tissue loss (Ulcer / Gangrene)and tissue loss

  1. Pressure areas and between toes (Ischemic ulceration – Gangrene)
  2. Skin and appendages (Temperature – Loss of hair – Loss of sebaceous and sweat glands – Dry skin – Deformed and brittle nails – Loss of nail luster – Xanthelesmata and xanthomata)
  3. Subcutaneous tissues (Loss of subcutaneous fat – Thin skin – Tapered toes)
  4. Venous guttering
  5. Muscles and tendons (Wasted muscle)
  6. Bones and joints (Osteoporosis)
Vascular angle (Buerger’s Angle)


  1. Temperature (and tenderness)
  2. Capillary refill
  3. Peripheral pulses


Continue reading “Peripheral arterial system – Clinical Examination”